PHRM 251 Lecture Notes - Lecture 3: Electronic Health Record, Drug Allergy, Admission Note
Document Summary
Serves as a communication tool of care provided by the physician and other health care providers: patient"s illness, care, treatment, outcomes. Electronic medical record computer-based and accessed electronically. Kept in nursing station do not remove. Patient"s paper record that is stored in health records. When admitted a request is made for the old records to be sent to the nursing unit. Historical therapeutic drug levels & response to therapy. Verification of drug allergy and time lines. When hospital stay is extended & patient"s paper record is too unmanageable. For pharmacists thinned charts may be useful for: Note : the original physician orders will remain in the chart. Describe how a patient"s medical records are organized. Admission note by admitting service (e. g. internal medicine or. Pain management flow sheet, blood glucose record, anticoagulation record. Transcriptions (discharge summary) *may also be in history. Includes all orders for a patient not just medications.
